Quantifying “Community Power” and “Racial Justice” in the Medical-Legal Partnership Literature

Abstract

Medical-Legal Partnerships (MLPs) have been widely acclaimed for promoting health equity and achieving meaningful outcomes. Yet, little to no research has analyzed if this critical work has been done with communities — through meaningful engagement and building power — or if it has been done for communities without their involvement.

Introduction

The Medical-Legal Partnership (MLP) model, established in 1993, is a highly successful national movement with its core being the partnering of medical providers and legal professionals to address health inequities.¹ MLP practice generally encompasses three core activities: (1) direct legal services co-located and integrated into the healthcare setting; (2) interprofessional training and education; and (3) policy and systemic advocacy work. Essentially, a health care provider identifies a health-harming legal need, connects a patient to a MLP lawyer, and a lawyer provides their expertise to meet this legal need. And together — doctors, lawyers, and patients (and patient communities) — collaborate to address “big picture” policy solutions. Health-harming legal needs are complex social problems that go beyond the expertise of the traditional health care team. The expertise of a lawyer can, for example, resolve individual patient problems ranging from family law and domestic violence needs to housing and income challenges, while also tackling issues of discrimination in the workplace, school, or other systems.²

The tremendous impact of the MLP movement is now widely known, and MLPs are cited in key policy papers in the traditional medical and legal fields. The American Academy of Pediatrics, for example, promotes the MLP model for combating such societal and health harming ills as childhood poverty,³ and much of the foundational health justice scholarship has grown out of the work of many MLP scholars and practitioners.⁴

One of the primary activities of the MLP model is to impact policy beyond the individual patient/client case, reaching broader community impact and heading “upstream” to address the root causes of the social determinants of health (SDOH). This upstream policy change requires clarity about our shared goals and values. And how we get there matters. For example, without careful thought towards building trusting relationships and supporting community power with the people we serve, MLPs run the risk of creating policy without the meaningful inclusion of patient/client communities.

As we begin our examination of how the MLP field practices justice, two approaches inform our focus on centering and building community power. From the medical field, the “medical home” concept is often used to place the patient at the center of all that is done.⁵ While the medical home was traditionally conceived as a centralized place of care, it has evolved to signify “partnership between health care professionals and families.”⁶ In the legal field, rebellious lawyering (also, community lawyering) describes an inclusive approach where “lawyers must know how to work with (not only on behalf of),” “to collaborate with,” and to be “educated by” the people they purport to serve.⁷ The authors have previously explored the concept of a “medical-legal home” to connect these two approaches in the MLP framework.⁸

As we begin our examination of how the MLP field practices justice, two approaches inform our focus on centering and building community power. From the medical field, the “medical home” concept is often used to place the patient at the center of all that is done. While the medical home was traditionally conceived as a centralized place of care, it has evolved to signify “partnership between health care professionals and families.” In the legal field, rebellious lawyering (also, community lawyering) describes an inclusive approach where “lawyers must know how to work with (not only on behalf of),” “to collaborate with,” and to be “educated by” the people they purport to serve. The authors have previously explored the concept of a “medical-legal home” to connect these two approaches in the MLP framework.

These concepts center the patient/client at the hub and characterize the direct legal services that MLPs engage in. The MLP model also encourages partnerships to go further, “leveraging their considerable knowledge and expertise to advance local and state policies that lead to safer and healthier environments.”⁹ Significantly, just as the patient/client must be central in the medical-legal home, so too must the patient/client community be central in any policy and advocacy work that affects them. The rebellious lawyering approach encourages communities to be active agents in policy change and equal problem solvers to the legal and medical professionals with whom they are allied.¹⁰ Thus, words like “community power” and “power building” are appropriate terms to describe the systemic impact work and policy advocacy at the community level when MLPs partner with communities.

Fostering and wielding effective community power demands a reckoning with the history and impact of racism in America. Thus, terms and concepts related to power cannot be discussed without consideration of racial justice, race, and ethnicity, as it is widely known that racism (interpersonal, institutional, and structural) negatively impacts health.¹¹ This discussion, however, has been woefully absent previously in MLP literature and the movement has faced internal critiques in this regard.¹² Indeed, as argued by one of our authors, “the critical element missing from the MLP approach is an examination of race and racism as a key structural system in the U.S. that impacts nearly every aspect of our work to improve health and wellness.”¹³

Further, in a white paper from the Brookings Institution, Dayna Bowen Matthew admonishes MLPs for not doing more to address racism’s role in the SDOH including in racial segregation in housing and racial inequities in education:

Given the strong legal prohibitions against racial and ethnic discrimination, and the evidence that prohibited discrimination is a primary driver of residential segregation and its health-harming effects, MLP activity on these legal issues could be more robust. MLPs are active, however, protecting against non-racial forms of discrimination.¹⁴ …

While some MLPs like those at Whitman-Walker Health in Washington, D.C. and the Crossroads Medical Clinic in Mississippi focus on removing discriminatory barriers that impact HIV/AIDS patients and the LGBTQ community, currently, no MLP in the nation focuses on reducing health disparities by broadly addressing racial and ethnic discrimination in education or any other social determinant of health.¹⁵

This is a striking criticism of an otherwise acclaimed model for reducing SDOH. This 2017 critique, however, may not reflect the current state of affairs. In her 2022 article, “Towards Racial Justice: The Role of Medical-Legal Partnerships,” Medha Makhlouf contends that “participants in academic MLPs have sought to align the MLP model with the health justice framework, which emphasizes the importance of racial injustice. However, this conception is still emerging and may not be widely known or accepted among researchers or MLP practitioners on the ground.”¹⁶ She also argues that MLP’s “original framing through a singular poverty lens” is now a barrier for MLP to overcome in reframing itself as a racial justice intervention.¹⁷

While the hypothesis that the MLP model is lacking in its examination of race and racism is held by some MLP academics, it has not been empirically shown that the published MLP research (as a studiable proxy for the model, movement, and practice) is lacking in this regard. As MLP is inherently multidisciplinary and its participants span from public health and medicine through law, discussion of this issue must engage all perspectives, from the qualitative arguments to the quantitative. Using bibliometric methods to study the MLP health literature, we quantified the observance of terms that illuminate concepts of “community power” and “power building,” “power and engagement” as well as “racial justice.” We hypothesized that these terms would be scant, but that perhaps due to a national time of racial reckoning, they may have increased.

Methods

Bibliometric analysis is a methodology drawn from the library and information science fields that make quantitative analyses about books, articles, journals, and other bibliographic items. It is a methodology increasingly important to quantify trends in fields such as medicine and humanities.¹⁸ As the MLP literature is inherently multidisciplinary, encompassing biomedical, humanities, and social science areas, Clarivate Web of Science database (WoS) was chosen for this study because, despite its name, it represents these fields well and thus allows for bibliometric analyses of citations and impact. In fact, WoS currently includes access to 411 of the top law journals (identified as the highest cited journals). Therefore, wherever the “literature” is referenced following, it should be read to refer to the contents of the WoS database, which excludes monographs and less well cited journals, especially in the humanities.

Systematic searches were performed in the WoS database, and four groups of records were collected, including articles in the past 5 years on MLPs, SDOH, and subsets of each which use terms relating to “community power” or “racial justice.” The search terms that defined articles for MLP and SDOH datasets were drawn from two existing systematic reviews. The specific terms and search strategy are shown in Appendix 1. The SDOH were used as a comparison group for this study for several reasons. SDOH are widely recognized as a key determinant of health outcomes, encompassing a range of factors such as income, education, housing, and access to healthcare.¹⁹ SDOH literature has a long history of being multidisciplinary and inclusive of various perspectives and disciplines, including public health, sociology, and medicine, comparable to the MLP literature. SDOH literature provides a baseline of research that has consistently been exploring the key concepts of community power, power building, and racial justice, making it an ideal comparison group to assess if these ideas are also being explored in the MLP literature.²⁰ Comparing the frequency of these concepts in the MLP literature to the SDOH literature can provide valuable insights into the evolving focus and priorities of MLP research and how it relates to broader discussions around health equity and community engagement.

To determine if racial justice papers have greater impact than average MLP papers, impact data was collected using both journal impact factors and altmetric impact factors. Altmetrics are the “alternative” metrics to traditional scholarly impact measures and include citation counts such as social media, news articles, and websites including Wikipedia, blogs, and public policy documents. These sources generally respond faster to changes in academic fields than the traditional impact factors that are tied to the slow process of journal publication.²¹ Altmetric rankings from Altmetric.com were retrieved for the same datasets, reflecting more immediate impact.²²

Journal Impact Factors (JIF) from the 2021 Journal Citation Reports were recorded for each MLP racial justice article and compared to the 2021 MLP article set. The JIF is a calculation of a journal’s citations, simply defined as the number of citations to articles within 2 years, normalized by the number of citable articles during that time period.²³ Although not without flaws, the JIF is widely considered to be a measure of the research impact of a journal.

Results

The study found that the proportion of SDOH literature mentioning racial justice terms increased from 3 percent in 2017 to 5 percent in 2022, as shown in Figure 1. In contrast, the proportion of MLP literature mentioning racial justice terms was far lower from 2017 to 2020, with no publications found in Web of Science to contain these terms. However, in 2021 and 2022, there was a significant increase in the proportion of MLP literature mentioning racial justice terms, with 20 percent of the publications in these two years containing such terms. This sudden increase in the proportion of MLP literature mentioning racial justice suggests a growing recognition and prioritization of this issue within the field.

Figure 1 Proportion of MLP and SDOH Literature with Racial Justice Terms

While the proportion of MLP literature mentioning racial justice terms increased in 2021 and 2022, the total number of MLP publications decreased over the same time period, shown in Figure 2. Appendix 2 shows the total number of articles in the dataset by year and for each subset. Because the MLP literature is small (9-23 publications per year in the last ten years), there is substantial fluctuation from year to year in the total publication rate. Yet, this decrease in the overall number of MLP publications suggests that the increase in racial justice papers is not an expansion of MLP literature into new areas, but a shift in focus. These findings indicate a shift in focus and prioritization within the MLP field towards addressing the intersections of race, justice, and health, irrespective of the total number of publications.

Figure 2 Total Publications and Social Justice Publications in the SDOH and MLP Literature Over Time

It was found that MLP papers with racial justice terms were published in lower impact journals, with a median 2021 impact factor of 2.42 compared to 2.72 for all MLP papers, but received higher altmetric impact activity as of January 15, 2023, as shown in Figure 3, with a median altmetric ranking of 0.75 compared to 0.64.

Figure 3 Comparative Journal and Altmetric Impact of MLP Racial Justice Papers

Discussion

While the MLP health literature is a small dataset in comparison to the control dataset of SDOH literature, there was a lack of usage of these terms prior to 2020. Compared to the SDOH control dataset, it is clear that this is not due to a global lack of usage, as there has been a constant presence of literature using these terms even prior to 2020. This supports what was previously argued by Makhlouf and Shek — that the MLP framework, specifically, has lacked a race consciousness despite the critical role that race and racism play in SDOH and health equity.²⁴ Makhlouf observed in her 2022 piece that the conception of racial justice as being central to health justice was perhaps not widely known or accepted among MLP researchers, academics, or the MLP practitioners on the ground.²⁵ Our data shows that perhaps this is beginning to change.

It could be reasoned that because the numbers are so small, there may be just a few researchers or academics who are using these terms and therefore this cannot reflect a true change in the model. However, we counter that the presence of this number of new articles in such a small literature is a substantial change (going from zero to 20 percent), as it makes up a large proportion of the published conversation regarding MLPs.

Indeed, 2020 was a year that exposed racial health disparities amidst a global pandemic and forced a renewed confrontation with America’s legacy of racism as exemplified by the broad support for the Black Lives Matter movement. Fittingly, one of the articles that was identified in the search methods is an introduction to a special issue in the Journal of Law, Medicine & Ethics, which specifically was undertaken “to use the tools at its disposal to advance the work of anti-racism in the realm of health law and policy” in the backdrop of the “nation’s current racial reckoning.”²⁶ The very notion of such a special issue dedicated to anti-racism in which the “dual nature of health law, with attention to … anti-racist teaching and practice in the context of building an interprofessional curriculum and medical-legal partnerships” among other critical topics supports our theory that MLP scholarship as a reflection of MLP practice is beginning to change.²⁷

An article from Australian medical-legal colleagues (whom term MLPs differently as “health justice partnerships”) seeks to further change the field by redefining the SDOH to “conceptually integrating the functions of the law.”²⁸ In their bold redefinitions they specifically address empowerment:

The third key element of legal capacity as a tool for health relies on capability or empowerment. Both individual and structural capability and empowerment are needed. Structurally, laws and legal processes need to provide a pathway to resolve health problems. But that capability alone does not guarantee that people will be able to use these pathways. Individually, people need to know that these pathways exist and to be empowered to use them. Building an understanding of how to use the law therefore becomes a critical step toward building or strengthening legal capacity as a tool for health.²⁹

Our study also sought to address the impact of the research that included the terms “community power” and “power building,” “power and engagement” and “racial justice.” It was found that the small number of MLP papers with racial justice terms were published in lower impact journals. This is likely because many of the “mainstream” MLP papers are published in traditional medical journals, which have higher impact factors. For example, The New England Journal of Medicine, has an impact factor of 176. However, specialized journals at the intersection of health and law may have lower impact factors because humanities disciplines have lower average citation rates due to differences in citation practices.³⁰

The MLP literature which included our search terms received higher altmetric impact activity than the mainstream medical literature. This is likely due to the fact that responding to MLP literature through citations or commentary in the traditional peer review literature requires the long time frame involved in academic publishing, whereas commenting on the literature can occur much more rapidly in the alternative realm of communication which encompasses such fast pace venues as social media or news articles. Thus, as altmetrics respond faster to changes in academic fields than citation factors, this finding supports our hypothesis that the MLP field is changing to be more inclusive of the ideas of community power and racial justice.

A limitation of this study that complicates the bibliometric study of the medical-legal literature (as is the case with any multidisciplinary field) is the siloed publication of articles in both traditional medical/health journals and legal journals/law reviews. For example, Shek’s article from 2019 was not found in the WoS search but was found in a search of the legal database, Legal Collection. As mentioned previously, while WoS does have good coverage of humanities, it is not a dedicated legal database and thus does not cover the full MLP literature. WoS includes over 400 top cited legal journals, comprising about a quarter of English language law journals.³¹ Thus, Shek’s article, and others published in lower ranked legal journals or law reviews, do not appear in this study’s findings.

One could argue that including the top cited legal literature is sufficient for this analysis, however, one might also conclude the opposite — that new ideas or research may be considered risky to publish by top academic journals whereas smaller niche, local, or less “impactful” journals may be willing to publish such articles as part of their own philosophy, to increase their own profile, or for other local agendas. Another possibility is that younger legal and medical scholars face barriers to publishing when compared to more established professionals and thus may be publishing in lower ranked journals which this analysis missed. Perhaps the number of articles related to community power and racial justice would be higher in recent years if multiple databases were searched.

While WoS contains tools that allow for analysis of impact factors, many other databases, including Legal Collection, do not, which make it impractical to combine data from different databases and still include the bibliometric analyses used in this study. Further study of the legal database using the same search terms is warranted. We hypothesize that similar trends will be present even if more MLP articles are identified in the legal literature. Such a study may also illuminate the question of why the MLP movement has been relatively slow to embrace racial justice and community power, and whether this trend mirrors traditional legal services and medical services for the poor and historically excluded. A future bibliometric study could also investigate the siloed nature of the health and legal MLP literature, the professional and practical impact of where MLP articles are published, and also identify what role journals, such as the Journal of Law, Medicine & Ethics, are playing in providing a space for MLPs’ inherently interdisciplinary work.

Finally, our focus on academic scholarship may under-recognize MLP practice that engages in building community power but has not been documented in traditional scholarship. Still, academic articles are primarily written by and about a cross-section of MLP practitioners and strongly reflect the field — and shifts in the field — of MLP practice.³² Altmetrics are one way to expand our understanding of these changes. For example, Makhlouf undertook a review of 241 websites finding that “only eighteen explicitly stated in their program mission or description an intention to serve Black, Indigenous, Latinx or people of color or used terminology such as ‘marginalized populations.’”³³ While websites cannot encapsulate the entirety of an MLP practice, this is still illuminating. Future surveys of websites and social media could be undertaken to study this more. Additionally, reviews of MLP law and medical school clinic syllabi as well as interviews with MLP faculty could elucidate what is being taught to the current generation of MLP students. And, to really get at what is happening in MLP practice — and how it is (or is not) reflected in the MLP literature — interviews with MLP partners and practitioners could document to what extent MLPs are promoting community power and advocating for racial justice.

The MLP field should also increase access to scholarly documentation by expanding the methods and means of scholarship. This includes considering non-traditional approaches to producing scholarship including methods such as co-authoring with practitioners and community partners, conducting and publishing interviews to document justice work and practice, and producing popular media and opinion pieces. Hosting and recording conferences, symposia, and workshops are also critical sources for uplifting justice-oriented MLP practice. Finally, the resources currently available at the National Center for Medical-Legal Partnership could be expanded to house a central repository of both formal and non-traditional scholarship.

Conclusion

We believe that the MLP field must continue to evolve to promote community power and to center racial justice in order to have the upstream impact in SDOH and policy that MLPs prioritize. Understanding where we are in the process, as demonstrated by our analysis of the MLP literature, is the first step in that evolution.

At the Medical-Legal Partnership for Children in Hawai’i (MLPC), we have previously written about our own evolving praxis, first recognizing the need to create a medical-legal home,³⁴ to centering a racial justice framework,³⁵ to now prioritizing our role in building community power.³⁶ Our next step towards strengthening community relationships and elevating community power is to invite our clients and community partners to dream and to build a shared vision of what kind of world they want. Inviting people to dream and listening to their dreams is a step towards seeing people for all their humanity. When we believe that people don’t dream — and don’t carry dreams for their children — we are taking a dangerous step towards dehumanizing them.³⁷ Perhaps having people simply share dreams together is a tool that more MLPs can use to build community power as Lopez urges us to do, by working with, not only on behalf of, the people we serve.³⁸ And as practice is reflected in the scholarship, perhaps future bibliometric search terms will include “dreaming” and “envisioning” as essential measures of MLP practice.

Indeed, several critical MLPC Hawai‘i collaborations grew out of moments when government and agency leaders made statements that our Micronesian client communities “have no dreams” and are “not responsive” to outreach. In one instance, our MLPC health center partner, Kōkua Kalihi Valley Comprehensive Family Services, hosted a gathering of Micronesian community leaders to meet with local law enforcement to identify collaborative solutions to juvenile justice concerns. At one point, a family court judge declared, “These parents have no dreams for their kids!” and in that moment, any hope of understanding and collaboration was gone.³⁹

Years later, in the earliest months of the COVID-19 global pandemic, a government health official claimed Micronesian pastors and leaders were “not responsive” to outreach efforts.⁴⁰ This claim was also repeated by the Honolulu Police Department following a police shooting and killing of a 16-year-old Micronesian boy.⁴¹ Contrary and in response to these perceptions, Micronesian leaders formed a Micronesian Ministers & Leaders Uut (Chuukese word for a gathering house) that has met every Tuesday night by Zoom videoconferencing since mid-2020 through today to address critical community issues including pandemic-related health education, community resource sharing, civil rights, and community justice matters.⁴² MLPC Hawai‘i staff was first invited to the Uut to discuss and address employment rights during the pandemic, and we became regular participants and co-organizers of the weekly gathering. The Uut is a place to share resources, organize community education, and also to dream and envision together. And from these opportunities to dream, we build a shared vision for our collective future, enlivening and guiding our MLP work.

While the MLP movement evolves to center community power — as evidenced by the shifts in scholarship in this study documenting MLP practice — we can look back 35 years to the words of Lucie White in her article titled, “Mobilization on the Margins of the Lawsuit: Making Space for Clients to Speak.” She urges us to consider that “A single moment of mobilization has some value, even when it makes no concrete contribution to the litigation effort.”⁴³ She continues:

For the clients, it creates a history, a context, for further action in the future. And for the lawyers, if they listen carefully, these moments can make them aware of their clients’ worlds, of the power and visions that their clients can bring to a shared project for change.⁴⁴

The MLP network is positioned to lead and transform traditional medical and legal service models to embrace these values and approaches, and to work alongside our patient/client communities, to dream and envision together, and to build our collective power.